How We Lie

Near end of his award-winning book, How We Die, Sherwin Nuland recounts story of Hazel Welch, his ninety-two-year-old patient who lived at senior citizen's residence about five miles from Yale-new Haven Hospital. Mentally alert, Ms. Welch required nursing care because of her advanced arthritis. One day she fell and was taken by ambulance to hospital. She was found to have perforated digestive tract but refused indicated surgery, saying she had lived on this planet quite long enough, young man. Nuland could not understand her decision. He told her that her chances of having successful surgery were one in three, versus certain death without it. When Nuland returned later she relented, saying, I'll do it, but only because I trust you.[1] The operation proved more difficult than anticipated, and when Ms. Welch could speak, more than week later, she reproached Nuland for operating. He realized that he was wrong to have insisted on surgery. Ms. Welch died of massive stroke two weeks after her transfer back to her residence. Nuland Writes, Had I chance to relive this episode ... I would listen more to patient and ask her less to listen to me. But, in next paragraph, he admits that it is a lie to think that he would have actually acted differently, because not to operate would have risked the scorn of my peers. He continues: It is in such matters that ethicists and moralists run aground when they try to judge actions of bedside doctors, because they cannot see trenches from their own distant viewing point. The code of profession of surgery demands that no patient as salvageable as Miss Welch be allowed to die if straightforward operation can save her, and we who would break that fundamental rule, no matter humanness of our motive, do so at our own peril. Viewed by surgeon, mine was strictly clinical decision, and ethics should not have been consideration. (p. 253) Phase I of SUPPORT study found that physicians, like Dr., Nuland, indicated that lack of good prognostic information and shortage of time to discuss treatment alternatives were major barriers to appropriate decisionmaking with hospitalized patients near end of life. These problems thus became targets of nurse-directed Phase II intervention. But SUPPORT could succeed only if these two targets outcome information and time for physician-patient exploration of alternatives) are true barriers to appropriate decisionmaking near death, and if they can be influenced by activities of specialized nurse. My own view (which finds support in SUPPORT study) is that neither assumption is correct. The problem is nature of hospital-based medical culture, and this culture cannot be changed by changing practice of nurses. Physicians simply have never taken rights of hospitalized patients seriously.[2] The most central season is that in modern teaching hospital, patient care is often distant third goal after teaching and research. In high-tech, high pressure environment, there is little room for thoughtfulness, for intrusion human values, or for conversation with patient or family. The primary values are action- and technology-oriented; imperative is to use all available medical technologies for patient or for practice. As hospitals become more and more like large ICUs, this impersonal, technological emphasis increases. Add cost pressures to treat patients more quickly, and care of dying in hospitals is likely to get worse, not better. Medical students and residents are taught that talking is waste of time, distracting from time available to do real medicine. And when even doing real medicine cannot help dying patient, students and residents quickly learn that attendings are uninterested in having discussions with patients or families about death or pain. …